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Month: August 2014

I was not having a good morning. I had just come off Trauma call – a difficult 24hr shift that was finally behind me. I had finished a long week of rounding on the Trauma Service and had turned the patients over to Sid, who would be the rounding Doc for the coming week. All I really wanted to do was to go home and sleep. Instead, I was in the operating room struggling through a laparoscopic cholecystectomy on a hot gallbladder.

The night had been particularly difficult because we’d had two deaths during the shift, both young people in a rollover car crash up on the Beeline Highway. One was dead at the scene, but the medics had transported her anyway, doing CPR all the way because she was just sixteen and had no external signs of injury. The x-ray we did in the trauma bay told why. She’d suffered an atlanto-axial dislocation. Her neck had been stretched or distracted during the accident, separating her head from the first cervical vertebra – essentially an internal decapitation. Immediately fatal most of the time.

The other patient, an eighteen-year-old boy was alive when he arrived but lost his vitals within a few minutes. We worked on him for almost an hour, but never even got him stable enough to go to the operating room.

I had to talk to two families and tell them that their children were dead. I don’t do that conversation well. One of my friends, herself a trauma surgeon, seems to know just what to say to families in these situations. She is quiet and calm, but her compassion and empathy for the loved ones of the patient comes through clearly. I have no words of comfort to give, no particular way to ease that blow. I tend to be very matter of fact and clinical when giving that kind of news and I’m sure I come across as cold and unfeeling. It leaves me feeling both inadequate and guilty for not being able to do more.

So, I was in a foul mood when I started the gall bladder surgery. The procedure was more difficult than expected. The gallbladder was thickened and inflamed and the anatomy wasn’t clear. I struggled and sweated and swore for almost an hour before I could identify the critical structures and safely get the gallbladder out.

I’ve written before about the Dance, that relationship between a surgeon and an assistant that keeps an operation flowing smoothly. I was definitely a half step off that morning. Michele did her best to keep up, but in the end, the operation was more of a slog through mud than a smooth dance.

I was not happy with my performance and it sharpened the feeling of incompetence brought on by the previous night’s events. At one point in the surgery I even shouted at the circulating nurse to ‘turn off the damn music’ so I could relay instructions to Michele and our surgical tech. We usually play music in the OR during a case. The hospital computer can pull Pandora and by unspoken agreement the circulator picks the music unless someone else strongly objects. That morning it was Motown. I don’t mind Motown, but it isn’t my favorite and that morning it got on my nerves.

I finished the case and left Michele to close the small laparoscopic incisions. I stripped off my gown and gloves and as I left the room, I heard the volume crank up on the radio, blasting Diana Ross and the Supremes as the door closed behind me.

By the time I reached the OR control desk, I was calmer. I noticed several techs standing around the desk watching one of the monitors that let the charge nurse observe what was happening in the operating rooms. I looked up to see my wife and LaVera, the scrub tech, dancing to the music of ‘Stop In The Name Of Love’, including all of the Supremes’ signature moves. I smiled for the first time that morning.

There’s an old adage in Surgery that says: “It takes two years to teach a resident how to operate and another three to teach a resident when not to operate.”

Surgery is an active profession. Above all the Surgeon is expected to take action, even when that involves the decision to NOT do surgery.

Surgical sins are different from Medical sins. There are sins of commission – hubris, arrogance, pride, vanity – all of which we are guilty of at one time or another during our careers. Some of them are also surgical strengths depending on the situation.

There are also the sins of omission – carelessness, sloth, ignorance, and perhaps the most egregious, indecision. As a mentor once said, “A surgeon doesn’t have to be right, but he has to be certain.”

It’s incumbent on us by the nature of what we do to people in surgery to be affirmative in making decisions. By that I mean, any decision should be made actively, through consideration of the action we are taking and its potential consequences.

But wait, aren’t all decisions made that way? No, not always. Delay, procrastination ‘watchful waiting’ often lead to a decision of indecision where the patient’s condition changes in spite of our attention rather than because of it. If I, as a surgeon, chose not to operate on a patient, it should be because I have a valid reason for expecting that the situation will resolve without surgery, or perhaps because the patient’s condition is such that surgery presents an unacceptable risk.

I recently decided not to operate on an elderly woman with free air in her abdomen. Free air means there is air outside of the bowel or lungs where it belongs. It implies a perforation in the bowel or stomach that is leaking stool or intestinal contents. Under most circumstances, it’s a surgical emergency.

I looked at this frail woman who was pleasantly demented with a history of heart disease and a recent stroke and thought, No way. It was a gut reaction born of a reluctance to take on a complicated and high-risk surgery. I rationalized it by observing that she was having little pain; that the air seemed scattered and was minimal in volume; that the CT that showed the air gave no indication of where the perforation might be and that she had a high risk of complications. I made a good case for NOT doing surgery, but knew it was a rationalization.

At first it seemed like the right decision. I started high dose antibiotics, put her on a limited diet and repeated her labs and x-rays. Her blood tests improved, she had no fever, her pain almost completely resolved and her intestine seemed to be working.

By the fourth day, however, it should have been clear to me that she wasn’t getting better. Still, I rationalized and procrastinated. She wasn’t getting worse, after all. I couldn’t (or more accurately wouldn’t) make a decision to abandon my original plan and take her to surgery.

By the seventh day it was obvious even to the internist that not operating wasn’t working. I took her to surgery and drained a large intrabdominal abscess and searched throughout her abdomen for the site of the perforation. I never found it. I suspect it was a pinhole perforation in a colon diverticulum, but even with aggressive manipulation of the area, I couldn’t demonstrate a hole.

She did not do well after surgery. She got more septic, her lungs and heart started to fail and after a long discussion with the intensive care internist, and me the family decided on palliative care only. She died a few hours later.

I don’t know if she would have survived if I had operated sooner. Perhaps the outcome would have been the same. I will never know. But I do know that my decision to not operate, while justifiable on paper, was not motivated by an objective look at her condition. And when it should have been clear that my initial management was failing, I procrastinated. The sin of indecision led to a delay far beyond what was objectively justified.

Anyone who has been in this business for a while can list his or her own secret tally of sins. I have committed sins of hubris, of arrogance, where I over estimated my capabilities and patients suffered and died for it. I have let pride push me to cling to a course of action when I should have changed course, and patients have been harmed. I have allowed fear or indecision or fatigue or stubbornness to hold me back from doing necessary surgery and patients have died. We all remember those cases but we tend to forget the times when we did the right thing. I can name far more patients that I have lost than ones that I have saved.

How a surgeon handles sin is a deeply personal process. I know some surgeons who simply ignore it. They are able to rationalize their actions and put it all down to patient disease, or at worst, a learning experience. Others become paralyzed by the fear of making an error and refuse to get involved in difficult or complex procedures. Still others internalize the guilt, refuse to let it stop them from continuing to take on the challenging or emergent cases, but ultimately pay a price in the form of sleepless nights and endless private second guessing of each decision.

Sometimes we have the opportunity to confess through the Morbidity and Mortality Conference (see M&M, another essay) and receive closure in the form of peer review of our actions. Even when the review recognizes our failing and chastises us for it, the philosophy of ‘forgive and remember’ is strong and the ritual lends a form of absolution.

Just as often, though, the sin is private. We know in our hearts what really motivated our action, and even when that action appears appropriate to an outside observer, we alone know how we failed. We must handle that and find a way to live with it if we are to serve our patients and retain our sense of purpose.

She’s 17 years old and going home tomorrow. Today we are working with Social Service and Case Management to get all the equipment she and her family will need for her ongoing care – dressing supplies, a walker, crutches, a wheelchair and a raised commode seat.

She’s 17 years old and three weeks ago I amputated her right leg above the knee. Before that operation she went through six surgeries to try to salvage the leg.

She’s just an ordinary kid. Not a star athlete, not a great student. She likes horses and Harry Potter and boating with family and friends on Lake Saguaro. She wonders if she’ll be able to graduate from high school this year, if she’ll ever be able to swim again, if she will be able to work as a hairdresser, which was her goal after graduation.

It was a weekend night full of fun and a few really bad decisions. Underage drinking, driving too fast on the 101 and a fight with her boyfriend all played a part. I wasn’t on when she came in, but was involved in her care as the rounding surgeon for the trauma service off and on for the whole six weeks she was in the hospital.

Her right leg got caught on something under the dashboard when the car rolled. Her boyfriend, who was driving, was ejected and died at the scene. Her right knee was dislocated posteriorly and the tibia and fibula, the two bones of the lower leg were shattered. Most of the skin on the lower part of her leg was degloved, ripped off of the underlying muscle. There was serious talk between the orthopedic surgeon and the trauma surgeon of completing the amputation that night. But she was 17 years old and healthy. Instead they went to surgery and did what they could.

Posterior knee dislocations are particularly devastating injuries because of the high incidence of injury to the popliteal artery. It’s the blood supply to everything below the knee and is runs through a narrow space right behind the lower end of the femur and upper end of the tibia. It’s relatively fixed in place by the big muscle groups around the joint and so when the tibia moves backwards in a posterior dislocation it can shear the vessel in two just like a guillotine.

The first goal in a vascular injury like this is to stabilize the bones. The leg will tolerate up to four hours of warm ischemia time, longer if the tissue is chilled, but vascular repairs are sensitive and don’t tolerate twisting, kinking or tension. If the bones aren’t secured, any repair will fail.

Popliteal arteries are hard to get at. Direct repair is rarely possible. More commonly a piece of vein is harvested and used to jump across the damaged segment from good vessel above to good vessel below.

In this case, there wasn’t much good vessel above or below. The artery hadn’t been sheared cleanly but rather had been stretched until it ripped. That caused unseen damage to the intima, the lining of the vessel, for a considerable distance above the visible tear. The degloving had also disrupted the vessels below the knee so there wasn’t much to jump a graft to down there.

The orthopedic surgeon put on an external fixator, an erector set like device of rods and pins that screw into the bone and attach to a lightweight external frame that keeps the bone from moving. The vascular surgeon did a vein graft and the trauma surgeon pulled what skin he could over the open wound. A vacuum dressing completed the first procedure.

I saw her on ICU rounds a few hours later and knew she was in trouble. Her blood was still acidotic, too much lactic acid in circulation, a sign of tissue that wasn’t getting enough oxygen. There was no detectable pulse below the knee and her toes were purple. The vascular surgeon took her back to surgery an hour later, and again six hours after that. And again. And again. All the time moving his graft to different tiny vessels in the lower leg looking for one that would support enough flow to nourish the muscles. One by one they shut down and the muscles died. After 18 days in the ICU on multiple antibiotics, sodium bicarbonate to correct the acidosis and heparin to keep the vessels from clotting off, we had the difficult conversation with her and her family.

I don’t dance. I have no rhythm and a tin ear. My attempts at dance, usually fueled by alcohol, amount to rocking back and forth or flailing about as if having some sort of bizarre seizure.

So it’s ironic that I married a classically trained dancer who realized after high school that she did not have the body to be a prima ballerina and decided to go to nursing school. Nevertheless, she regularly took master’s classes with the American Ballet Theater during time she was in college at Georgetown. For her, trying to dance with me is an exercise in saintly patience combined with steel-toed shoes.

It’s different in the operating room. She has been my first assistant for twenty years and when we operate together, it’s as close to dancing together as we will ever get. There is a rhythm to surgery, a practiced flow of movement and action not unlike a dance. When two people have worked together for a long time, they learn to anticipate each other’s moves and respond without cues or conversation, just like practiced dance partners. It’s actually harder for a surgeon to be a good assistant than for a nurse or technician. Surgeons tend to want to control the operation and forget their job is to make the operating surgeon look good. It’s like both partners in a dance trying to lead at the same time. A good assistant, like a good dance partner, knows when to lead, when to follow, and how to make the dance flow smoothly. They can’t make a poor surgeon look good, but they can make a good surgeon look great.

I have often felt this strange symphony of motion in the operating room with a good assistant. Athletes refer to it as being ‘in the zone’, and I suppose skilled practitioners in any field have a similar experience.

My wife and I dance well together in surgery, in part because we have always been on the same wavelength and in part because she has a natural understanding of physical movement. Her dance experience has given her a grace and economy of motion that never fail to excite and impress me. There is no one I’d rather have with me on a complex robotic or laparoscopic case. Dancing in the OR is a form of intimacy as intense as any on the ballroom floor.

It’s a rainy Saturday night, a welcome rarity in the Phoenix Valley. It’s not the hard rain of the August monsoons, but a light, steady winter rain. The Emergency Room has been fairly quiet and the trauma service has had no calls since change of shift twelve hours earlier. That is about to change.

The pagers don’t all go off at once, but rather in a rolling wave from the trauma nurse to the lab tech to the x-ray tech and finally to the trauma surgeon. The small green screens all deliver the same message:

“Level one by ground, ETA 10 min, RED

“GSW to chest and abdomen, no vitals given”

The team gathers in ER bay 53, one of four trauma bays, all prestocked with equipment and supplies above and beyond the normal emergency room requirements. There are sterile instrument packs for central line insertion, chest tube trays, suture trays and an emergency thoracotomy pack. There are rapid infusers – IV pumps that can push fluids at rates of 250cc to 400cc per minute; pneumatic tourniquets; a cast cart with webbing and plaster; and the usual stock of sterile gloves, gauze, and suture.

The conversation is light, that of people who have worked together many times before, greeting one another and bantering. A dark haired woman enters and moves to the head of the ER gurney that occupies the center of the bay. She is young, of medium height and build; attractive in spite of the almost shapeless surgical scrubs she wears and the lack of make-up. She would look nice in a short summer dress on the patio of a Scottsdale nightspot or strolling in La Condesa in Mexico City.

A few minutes later the ER clerk announces over the intercom, “Trauma is here in 53”, and the light banter ceases. Eyes swing to the paramedics moving quickly but purposefully into the bay.

For the first time the dark haired woman speaks, “Go ahead with report,” she says with a light Mexican Spanish accent.

One of the paramedics speaks out, “28 year old male shot twice, once in the left chest, entry just below the nipple, exit posterior near the tenth rib. Second wound enters in the left flank, exits in the right upper quadrant. Pressure has been low, in the 70’s systolic; pulse 130. No breath sounds on the left. We started two IV’s, 18 gauges in the right forearm and in the left antecubital. He’s gotten 900cc of saline en route and 100 mikes of fentanyl.”

“Thank you,” says the dark haired woman, already pressing a stethoscope to the man’s chest as a nurse wields surgical shears, cutting away his bloody clothing. Other techs move in attaching oximetry and EKG monitors, checking the integrity of the IV lines and removing his shoes and pants.

“I want to set up for a chest tube on the left and we’ll need the O negative emergency blood,” says the woman, clearly taking charge of the team. She glances at the monitors. “Better call the blood bank and start the massive transfusion protocol and tell the OR to set up for a laparotomy.”

Rapidly but clearly she calls out the list of his wounds, his breath sounds, his other physical findings. She asks him if he has other medical issues; if he takes medications; if he has any drug allergies; all the while doing a quick head to toe exam.

She pulls on sterile gloves and sets out the instruments she will need to insert a drainage tube into the left side of the man’s chest in order to drain blood and reinflate his collapsed lung.

A technician asks, “What size tube, Dr. C?”

The trauma surgeon, for that is who the dark haired woman with the slight Mexican accent is, answers, “34 French,” without looking up from her work. She trusts the technician to get the right tube and have it ready by the time she has made a small incision in the patient’s skin and probed through the muscle into the chest cavity. She inserts the tube and a rush of air and blood flows through it into a collection device. She secures the tube with a few quick sutures.

“Alright people, lets package him and move.”

By this time, the rapid infusers have pumped almost 500cc of red blood cells, an equal volume of plasma, and a liter of saline into the man’s veins. His blood pressure is better, although still low, and his heart rate has slowed, signs that the fluids have helped replace some of what he has lost.

The side rails of the gurney are raised and it starts to move, pushed by the trauma nurse who watches the electronic readout of his pulse and blood pressure on the small screen mounted by his feet. Techs follow closely, pushing the IV poles and keeping the lines from becoming tangled.

Eighteen minutes after arrival, he reaches the operating room, a bit better than average but not a record. Twenty-three minutes after arrival and five after reaching the OR he has been anesthetized, scrubbed, and draped and the surgeon makes her first incision.

Two hours and forty-seven minutes later the incision is closed and the patient is being moved from the OR table to an ICU bed. He will remain intubated and on a ventilator for the rest of the night. The bullet tore off a piece of his left kidney, lacerated his pancreas, shredded his splenic artery and punched through his stomach and liver before exiting the front of his abdomen.

In a single operation, the trauma surgeon over sewed the bleeding upper pole of the patient’s kidney, took out his spleen, removed the tail of his pancreas, removed a short segment of small intestine and put the ends back together, closed two holes in his stomach and cauterized bleeding areas in his liver. She placed drains in the area and closed her incision.

She follows the gurney to the elevator for the short ride up one floor to the surgical intensive care unit. She gives orders for his ventilator settings, his IV fluids, antibiotics, and mundane things such as dressing and drain care. Over the next twelve hours she will monitor his oxygen levels and vital signs, adjust fluids and ventilator settings, check on his urine output and review his morning x-rays.

Three days later, he is leaking bile from one of his drains, a potential sign of an intestinal leak. She takes him back to surgery and explores the abdomen. The bile is leaking from the liver wound. The intestine is intact and the bile leak is fixed with a single stitch.

His recovery is slow – his lung doesn’t seal right away, his intestine shuts down for almost a week before opening up, he leaks pancreatic fluid from his drain – but he survives and goes home twenty days after being shot.

This is a summary of an actual case handled by one of my colleagues. It is unusual only because penetrating trauma is unusual in my trauma center, accounting for just twelve percent of all admissions. What is common to all of the injuries we handle is the team approach with the trauma surgeon as the team leader. Also key is the ability of that surgeon to handle a wide variety of surgical problems across multiple specialties – in this case, a kidney repair, a splenectomy, a partial pancreatectomy, repair of stomach and intestine, repair of the liver, ventilator management, critical care management, antibiotic selection, wound management and discharge planning.

Trauma surgery mixes general surgery at its best with critical care medicine. It requires a good grounding in orthopedics, neurosurgery, plastic surgery, chest and vascular surgery, and emergency medicine. Even if you aren’t going to be the one actually operating on a complex fracture or a brain hemorrhage, you need to know what you are looking at and understand the principals of managing those problems so that you can communicate effectively with the consultants you call. You never know what’s going to come through the ER door on any given day.